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Adult Weight Management

AWM: Guideline Overview (2022)

Guideline Overview 

Guideline Title 
Adult Weight Management Evidence-Based Nutrition Practice Guideline (2022)

Guideline Narrative Overview 

Introduction

Overweight and obesity affect most adults living in the United States (U.S.).1 Excess adiposity, typically assessed with body mass index (BMI), 2 is causally linked to the development of many adverse health outcomes, including but not limited to mortality, risk of cardiovascular disease (CVD), pre-diabetes, and type 2 diabetes mellitus (T2DM).3-7 There are large healthcare and societal costs to the high prevalence of overweight and obesity.8 Weight management interventions are prospectively associated with beneficial health outcomes in adults with obesity, including improved quality of life (QoL) and all-cause mortality.9, 10 Research has demonstrated that weight loss interventions can decrease mortality risk for ≥4 years.10 The factors contributing to widespread prevalence of overweight and obesity are complex. Lifestyle behaviors and their consequent outcomes are affected by many factors outside of individual control, including but not limited to genetics, social determinants of health (SDoH) and health inequities, food and physical activity environment, food access, and weight bias and stigma.7, 11 Thus, addressing high rates of overweight and obesity requires creating compassionate solutions that can be tailored to a wide variety of adults who each face unique motivations for and barriers to reaching health goals. 

Registered dietitian/nutritionists (RDNs) or international equivalents (collectively referred to as ‘dietitians’ in the text of this guideline) collaborate with each patient and client (referred to as ‘client’ in this guideline) and other healthcare professionals to meet client-centered goals. This is achieved by individualizing interventions based on shared decision-making informed by the best available evidence, and translated through a lens of clinical expertise and client circumstances and preferences.12, 13 Dietitians provide medical nutrition therapy (MNT) interventions under the framework of the nutrition care process (NCP), which ensures interventions are tailored to the needs of each individual client based on nutrition assessment.13, 14 The NCP can elucidate client goals and barriers and facilitators to reaching those goals. Shared decision-making between the client and the dietitian helps to prioritize feasible and realistic actions that each client can incorporate to improve health and well-being. Most evidence available on the efficacy of interventions provided by dietitians for adults with overweight and obesity has focused on improving intake of nutrient-dense foods and reducing caloric intake, often in combination with increased physical activity, to facilitate weight loss and associated outcomes.15 Translation of this evidence into effective practice requires that dietitians consider clients and circumstances beyond those described in research studies to provide compassionate, equitable care that is applicable to a diverse clientele with a wide range of goals and values. 

In 2014, the Academy of Nutrition and Dietetics (Academy) authored an evidence-based practice guideline (EBPG) for adult weight management (AWM) on the Evidence Analysis Library website.16 The 2014 AWM EBPG was based on systematic reviews conducted from 2008 to 2013.16 Since that time, considerable research has been conducted in the field of adult overweight and obesity management. Additionally, circumstances and issues confronting dietitians have evolved, including, but not limited to, increased recognition of the role of weight bias in healthcare, the need for individualization of interventions to deliver effective care, and improved technology to deliver care via telehealth. Thus, updated guidance for MNT interventions provided by dietitians for adults with overweight and obesity is needed. 

The objective of this EBPG is to provide evidence-based recommendations for dietitians providing behavior change-based nutrition interventions for adults (≥18 years of age) with overweight and obesity to improve cardiometabolic outcomes, QoL, and weight outcomes, when appropriate for and desired by the client. While this EBPG is aimed at dietitians, other practitioners working with adults with overweight or obesity, such as primary care physicians, endocrinologists, cardiologists, bariatricians, nurses, nurse practitioners, and psychologists may find recommendations and implementation considerations in this guideline useful to inform practice. Recommendations are meant to serve as a guide for practitioners but do not replace clinical judgements which are made within specific contexts. Recommendations are not meant to represent the exclusive course of action in the management of overweight, obesity, or cardiometabolic disease. Practitioners using these recommendations are responsible for evaluating the appropriateness of each recommendation for each of their clients.

Guideline Development

This EBPG is meant to inform clinical decisions for dietitians providing MNT interventions for adults (≥18 years of age) managing overweight or obesity (body mass index (BMI) ≥25 kg/m2 or as defined for specific adult populations), including those with cardiometabolic disease such as T2DM or CVD. This EBPG is not intended for clients with eating disorders or diagnoses such as cancer, chronic kidney disease and other conditions for which weight loss may be contraindicated.

This guideline is based on a systematic review conducted by the project team, consisting of RDNs who are practitioners and/or researchers, systematic review and guideline methodologists and evidence analysts. Recommendations were written based on an evidence-to-decision framework that incorporates evidence as well as clinical experience and client values. When there was no evidence available for specific research questions, recommendations were based on expert experience and other supporting evidence. 

Click to view the specific methods for the development of this guideline,  

Topics addressed in this Evidence-based Nutrition Practice Guideline include:

  • MNT Approach for Adults with Overweight or Obesity
    • Utilize the Nutrition Care Process
    • Provide Medical Nutrition Therapy
    • Adapt Goals and Interventions
    • Minimize Weight Bias and Stigma
  • Coordination of Care
    • Collaborate with Interprofessional Healthcare Team
    • Coordinate Care in a Variety of Settings
  • MNT Amount
    • Number and Frequency of Interactive Contacts
    • Intervention Duration
    • Follow-Up Contacts
  • Delivery of MNT
    • Telehealth and In-Person Care
    • Group and Individual Contacts
  • Payment for Services
  • Dietary and Lifestyle Intervention Approaches
    • Dietary Patterns
    • Components of a Comprehensive Intervention
  • Special Populations
    • Co-Morbidities
    • Pharmacotherapy and Metabolic and Bariatric Surgery
    • Members of Groups Disproportionately Affected by Overweight or Obesity and Under-Resourced Communities

The number of supporting documents for these topics is:

  • Recommendations: 17
  • Conclusion Statements: 81
  • Evidence Summaries: 71
  • Article Worksheets: 87

To learn about the Academy's systematic review methodology and guideline development process,  visit the Policy and Procedures section of the Evidence Analysis Library (EAL).

Contributors

Expand the section titled Project Team and Disclosures to see the list of individuals who developed this guideline.

Revision

Academy guidelines are revisited every five years. An expert workgroup will be convened by the Workgroup Selection subcommittee of the Council of Research (COR) to determine the need for new and revised recommendations based on the available science. The process includes:

  • Conduct a scoping review to identify new research published since the previous searches were completed. Updated inclusion/exclusion criteria and search terms may be warranted.
  • Review to determine if the update will include modifications to recommendations and compare them to the earlier version of the guidelines, or development of new recommendations.

References:

  1. Centers for Disease Control and Prevention. Adult Obesity Facts. https://www.cdc.gov/obesity/data/adult.html. Published 2021. Accessed June 30,, 2021.
  2. Centers for Disease Control and Prevention. Defining Adult Overweight & Obesity. Division of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion. https://www.cdc.gov/obesity/basics/adult-defining.html. Published 2021. Accessed April 21, 2022.
  3. Yeh TL, Chen HH, Tsai SY, Lin CY, Liu SJ, Chien KL. The Relationship between Metabolically Healthy Obesity and the Risk of Cardiovascular Disease: A Systematic Review and Meta-Analysis. J Clin Med. 2019;8(8).
  4. Yu HJ, Ho M, Liu X, Yang J, Chau PH, Fong DYT. Association of weight status and the risks of diabetes in adults: a systematic review and meta-analysis of prospective cohort studies. Int J Obes (Lond). 2022.
  5. Jayedi A, Rashidy-Pour A, Khorshidi M, Shab-Bidar S. Body mass index, abdominal adiposity, weight gain and risk of developing hypertension: a systematic review and dose-response meta-analysis of more than 2.3 million participants. Obes Rev. 2018;19(5):654-667.
  6. Opio J, Croker E, Odongo GS, Attia J, Wynne K, McEvoy M. Metabolically healthy overweight/obesity are associated with increased risk of cardiovascular disease in adults, even in the absence of metabolic risk factors: A systematic review and meta-analysis of prospective cohort studies. Obes Rev. 2020;21(12):e13127.
  7. Centers for Disease Control and Prevention. Adult Obesity Causes & Consequences. https://www.cdc.gov/obesity/adult/causes.html. Published 2021. Accessed September 17, 2021.
  8. Tremmel M, Gerdtham UG, Nilsson PM, Saha S. Economic Burden of Obesity: A Systematic Literature Review. Int J Environ Res Public Health. 2017;14(4).
  9. Peckmezian T, Hay P. A systematic review and narrative synthesis of interventions for uncomplicated obesity: weight loss, well-being and impact on eating disorders. J Eat Disord. 2017;5:15.
  10. Kritchevsky SB, Beavers KM, Miller ME, et al. Intentional weight loss and all-cause mortality: a meta-analysis of randomized clinical trials. PLoS One. 2015;10(3):e0121993.
  11. Wu YK, Berry DC. Impact of weight stigma on physiological and psychological health outcomes for overweight and obese adults: A systematic review. J Adv Nurs. 2018;74(5):1030-1042.
  12. Jortberg B, Myers E, Gigliotti L, et al. Academy of Nutrition and Dietetics: standards of practice and standards of professional performance for registered dietitian nutritionists (competent, proficient, and expert) in adult weight management. J Acad Nutr Diet. 2015;115(4):609-618.e640.
  13. Academy of Nutrition and Dietitics. Academy of Nutrition and Dietetics: Revised 2017 Scope of Practice for the Registered Dietitian Nutritionist. J Acad Nutr Diet. 2018;118(1):141-165.
  14. Swan WI, Vivanti A, Hakel-Smith NA, et al. Nutrition Care Process and Model Update: Toward Realizing People-Centered Care and Outcomes Management. J Acad Nutr Diet. 2017;117(12):2003-2014.
  15. Cheng FW, Garay JL, Handu D. Weight Management Interventions for Adults With Overweight or Obesity: An Evidence Analysis Center Scoping Review. J Acad Nutr Diet. 2020.
  16. Academy of Nutrition and Dietitics' Evidence Analysis Center. ADULT WEIGHT MANAGEMENT (AWM) GUIDELINE (2014). Academy of Nutrition and Dietitics' Evidence Analysis Center. https://www.andeal.org/topic.cfm?menu=5276&cat=4688. Published 2014. Accessed August 23, 2021.
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